Provider Demographics
NPI:1295187540
Name:ABRAHAM LEWIS, GRACE M
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:M
Last Name:ABRAHAM LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8043 WINDING WOOD RD APT 14
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6539
Mailing Address - Country:US
Mailing Address - Phone:443-449-9991
Mailing Address - Fax:
Practice Address - Street 1:8043 WINDING WOOD RD APT 14
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6539
Practice Address - Country:US
Practice Address - Phone:443-449-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8137101YM0800X
MDLPG7130101YM0800X
MDLGP7130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA-165-288-566-121Medicaid
MD1295187540Medicaid